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Bandyopadhyay A, Kumar P, Jafra A, Thakur H, Yaddanapudi LN, Jain K. Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial. Anesth Analg 2023; 136:913-919. [PMID: 37058727 DOI: 10.1213/ane.0000000000006171] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Critically injured patients who are agitated and delirious on arrival do not allow optimal preoxygenation in the emergency area. We investigated whether the administration of intravenous (IV) ketamine 3 minutes before administration of a muscle relaxant is associated with better oxygen saturation levels while intubating these patients. METHODS Two hundred critically injured patients who required definitive airway management on arrival were recruited. The subjects were randomized as delayed sequence intubation (group DSI) or rapid sequence intubation (group RSI). In group DSI, patients received a dissociative dose of ketamine followed by 3 minutes of preoxygenation and paralysis using IV succinylcholine for intubation. In group RSI, a 3-minute preoxygenation was performed before induction and paralysis using the same drugs, as described conventionally. The primary outcome was incidence of peri-intubation hypoxia. Secondary outcomes were first-attempt success rate, use of adjuncts, airway injuries, and hemodynamic parameters. RESULTS Peri-intubation hypoxia was significantly lower in group DSI (8 [8%]) compared to group RSI (35 [35%]; P = .001). First-attempt success rate was higher in group DSI (83% vs 69%; P = .02). A significant improvement in mean oxygen saturation levels from baseline values was seen in group DSI only. There was no incidence of hemodynamic instability. There was no statistically significant difference in airway-related adverse events. CONCLUSIONS DSI appears promising in critically injured trauma patients who do not allow adequate preoxygenation due to agitation and delirium and require definitive airway on arrival.
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Affiliation(s)
- Anjishnujit Bandyopadhyay
- From the Department of Anaesthesia and Intensive care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Moghaddam NM, Fathi M, Jame SZB, Darvishi M, Mortazavi M. Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit. Acute Crit Care 2023; 38:113-121. [PMID: 36935540 PMCID: PMC10030249 DOI: 10.4266/acc.2022.00927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/01/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI). METHODS From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients' demographic, clinical, and laboratory features. RESULTS EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81). CONCLUSIONS A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.
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Affiliation(s)
- Nader Markazi Moghaddam
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
- Critical Care Quality Improvement Research Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Fathi
- Critical Care Quality Improvement Research Center, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Anesthesiology, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sanaz Zargar Balaye Jame
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), Department of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Morteza Mortazavi
- Department of Health Management and Economics, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran
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York S, Yates A, Frisch A. Emergeny Medicine Resident Trauma Intubation Success and Prior Intubation Experience. J Emerg Med 2023; 64:230-235. [PMID: 36806433 DOI: 10.1016/j.jemermed.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/09/2022] [Accepted: 12/13/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND Emergency medicine residents are often involved in the management of trauma airways. There are few data on the correlation between prior intubation experience and first-pass trauma intubation success for emergency medicine residents. OBJECTIVES We attempted to elucidate a relationship between prior resident intubation experience and first-pass success for trauma patient intubation. METHODS We combined two data sets to assess for correlation between prior intubation experience for postgraduate year 2 and 3 residents and first-pass success for trauma patient intubation. Prior intubation experience was gathered from resident procedure logs and trauma intubation data were collected as part of a quality-monitoring program. A univariable logistic regression analysis for all available variables was performed, with first-pass intubation success as the outcome of interest. RESULTS We included 295 consecutive trauma patients intubated at a Level I trauma center where we could link the resident prior intubation experience (total intubations) with intubation attempt quality data. First-pass success for all emergency medicine residents was 82.3% (233/283). Overall successful intubation rate for emergency medicine residents was 90.4% (256/283). The combination of airway management by both the resident and emergency medicine attending provided an overall success rate of 97.3% (287/295). There was no statistically significant association between first-pass success and prior resident intubation experience or any of the other measured variables. CONCLUSION We did not demonstrate any significant correlation between first-pass intubation success and number of prior intubations performed by the emergency medicine resident.
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Affiliation(s)
- Samuel York
- Emergency Medicine Residency Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam Yates
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam Frisch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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The Need to Routinely Convert Emergency Cricothyroidotomy to Tracheostomy: A Systematic Review and Meta-Analysis. J Am Coll Surg 2022; 234:947-952. [DOI: 10.1097/xcs.0000000000000114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nasal intubation for trauma patients and increased in-hospital mortality. Eur J Trauma Emerg Surg 2022; 48:2795-2802. [DOI: 10.1007/s00068-022-01880-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/04/2022] [Indexed: 11/03/2022]
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Altintas E, Bayram B, Colak Oray N, Oniz A, Karsli E, Tokgoz D. Bispectral index scores predicting complications after tracheal intubation. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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The Success Rate of Endotracheal Intubation in the Emergency Department of Tertiary Care Hospital in Ethiopia, One-Year Retrospective Study. Emerg Med Int 2021; 2021:9590859. [PMID: 33828865 PMCID: PMC8004359 DOI: 10.1155/2021/9590859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 02/07/2021] [Accepted: 03/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background Emergency medical care starts with airway assessment and intervention management. Endotracheal intubation is the definitive airway management in the emergency department (ED) for patients requiring a definitive airway. Successful first pass is recommended as the main objective of emergency intubation. There exists no published research regarding the success rates or complications that occur within Ethiopian hospitals emergency department intubation practice. Objective This study aimed to assess the success rate of emergency intubations in a tertiary hospital, Addis Ababa, Ethiopia. Methodology. This was a single institute retrospective documentation review on intubated patients from November 2017 to November 2018 in the emergency department of Addis Ababa Burn Emergency and Trauma Hospital. All intubations during the study period were included. Data were collected by trained data collectors from an intubation documentation sheet. Result Of 15,933 patients seen in the department, 256 (1.6%) patients were intubated. Of these, 194 (74.9%) were male, 123 (47.5%) sustained trauma, 65 (25.1%) were medical cases, and 13(5%) had poisoning. The primary indications for intubation were for airway protection (160 (61.8%)), followed by respiratory failure (72(27.8%)). One hundred and twenty-nine (49.8%) had sedative-only intubation, 110 (42.5%) had rapid sequence intubation, and 16 (6.2%) had intubation without medication. The first-pass success rate in this sample was 70.3% (180/256), second-pass 21.4% (55/256), and third-pass 7.4% (19/256), while the overall success rate was 99.2% (254/256). Hypoxia was the most common complication. Conclusion The intubation first-pass success rate was lower than existing studies, but the overall intubation success rate was satisfactory.
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Piastra M, De Bellis A, Morena TC, De Luca D, Pezza L, Pizza A, Genovese O, Mancino A, Picconi E, Conti G. Noninvasive Ventilation in a Pediatric Trauma Center: A Cohort Study. J Intensive Care Med 2021; 37:177-184. [PMID: 33461370 DOI: 10.1177/0885066620983744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether non-invasive ventilation (NIV) can avoid the need for tracheal intubation and/or reduce the duration of invasive ventilation (IMV) in previously intubated patients admitted to the pediatric intensive care unit (PICU) and developing acute hypoxemic respiratory failure (AHRF) after major traumatic injury. STUDY DESIGN A single center observational cohort study. SETTING Pediatric ICU in a University Hospital (tertiary referral Pediatric Trauma Centre). POPULATION During the 48-month study period, 276 patients (median age 6.4 years) with trauma were admitted to PICU; among 86 of them, who suffered from AHRF and received ventilation (IMV and/or NIV) for more than 12 hrs, 32 patients (median age 8.5 years) were treated with NIV. INCLUSION/EXCLUSION CRITERIA Inclusion criteria: at least 12 hours of NIV; exclusion criteria: patients with facial trauma or congenital malformations; patients receiving IMV <12 hours or perioperative ventilation. MEASUREMENTS AND RESULTS Among NIV patients, 27 (84,3%) were previously on IMV, while 5 (15,6%) could be managed exclusively with NIV. In patients with post-extubation respiratory distress, NIV was successful in 88.4% of cases. Before starting NIV, P/F ratio was 242.7 ± 71. After 8 hours of NIV treatment, a significant oxygenation improvement (PaO2/FiO2 = 354.3 ± 81; p = 0.0002) was found, with no significant changes in carbon dioxide levels. A trend toward increasing ventilation-free time has been evidenced; NIV resulted feasible and generally well tolerated. CONCLUSIONS AHRF in trauma patients is multifactorial and may be due to many reasons, such as lung contusion, aspiration of blood or gastric contents. Systemic inflammatory response and transfusions may also contribute to hypoxia. Our pilot study strongly suggests that NIV can be applied in post-traumatic AHRF: it may successfully reduce the time of both invasive ventilation and deep sedation. Further data from controlled studies are needed to assess the advantage of NIV in pediatric trauma.
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Affiliation(s)
- Marco Piastra
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart of Rome, Rome, Italy
| | - Andrea De Bellis
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Plastic Surgery and Burn Unit, S. Eugenio Hospital, Rome, Italy
| | - Tony C Morena
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniele De Luca
- Centre Antoine Beclere, Paris-Saclay University Hospitals APHP, Division of Pediatrics and Neonatal Critical Care, Paris, Ile-de France, France
- Université Paris-Saclay APHP, Physiopathology and Therapeutic Innovation Unit INSERUM U999, Paris, Ile-de France, France
| | - Lucilla Pezza
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Pizza
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Orazio Genovese
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Aldo Mancino
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enzo Picconi
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart of Rome, Rome, Italy
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Roshan R, Dhanapal SG, Joshua V, Madhiyazhagan M, Amirtharaj J, Priya G, Abhilash KP. Aspiration during Rapid Sequence Induction: Prevalence and Risk Factors. Indian J Crit Care Med 2021; 25:140-145. [PMID: 33707890 PMCID: PMC7922444 DOI: 10.5005/jp-journals-10071-23714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Securing definitive airway with minimal complications is a challenging task for high-volume emergency departments (ED) that deal with patients with compromised airway. Materials and methods We conducted a prospective observational study between September 2019 and March 2020. Cohort of adults presenting to the ED requiring rapid sequence induction (RSI) were recruited to determine the prevalence and risk factors for the development of aspiration pneumonia(AP) in patients intubated in the ED. Results During the study period, a total of 154 patients with a mean age of 44.5 years required RSI in the ED. Male (61%) predominance was noted among the study cohorts. We did not find any association between RSI performed in the ED and the risk of developing AP. The first attempt success rate of RSI was 76.7%, and 33(21.4%) patients had immediate adverse events following RSI. Rescue intubation was required for 11(7.1%) patients. The prevalence of AP following RSI in the ED was 13.4%. Endotracheal tube (ET) aspirate pepsin was positive in 45(29.2%) samples collected. The ET aspirate pepsin assay had low sensitivity (44.44%), specificity (73.53%), positive predictive value (18%), and negative predictive value (91%) in predicting the occurrence of AP. On multivariate logistic regression analysis, male gender (AOR: 7.29, 95%CI: 1.51-35.03, p = 0.013) and diabetes mellitus (AOR: 3.75, 95%CI: 1.23-11.51, p = 0.02) were found to be independent risk factors for developing AP. Conclusion We identified male gender and diabetes mellitus to be independent predictors of risk of developing AP after RSI in the ED. ET aspirate pepsin levels proved to be neither sensitive nor specific in the diagnosis of AP. How to cite this article Roshan R, Sudhakar GD, Vijay J, Mamta M, Amirtharaj J, Priya G, et al. Aspiration during Rapid Sequence Induction: Prevalence and Risk Factors. Indian J Crit Care Med 2021;25(2):140-145.
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Affiliation(s)
- Ramgopal Roshan
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sudhakar G Dhanapal
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vijay Joshua
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mamta Madhiyazhagan
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jayakumar Amirtharaj
- Department of Clinical Biochemistry, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ganesan Priya
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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Park CY, Kim OH, Chang SW, Choi KK, Lee KH, Kim SY, Kim M, Lee GJ. Part 3. Clinical Practice Guideline for Airway Management and Emergency Thoracotomy for Trauma Patients from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Prause G, Orlob S, Auinger D, Eichinger M, Zoidl P, Rief M, Zajic P. [System and skill utilization in an Austrian emergency physician system: retrospective study]. Anaesthesist 2020; 69:733-741. [PMID: 32696083 PMCID: PMC7544713 DOI: 10.1007/s00101-020-00820-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/14/2020] [Accepted: 06/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The continuous rise in calls for emergency physicians and the low proportion of indicated missions has led to a loss of job attractiveness, which in turn renders services in some areas unable to sufficiently staff units. This retrospective analysis evaluated the frequency of emergency and general medical interventions in a ground-based emergency physician response system. METHODS A retrospective analysis of anonymized data from the electronic documentation system of the emergency physician response unit at the Medical University of Graz was carried out. Calls answered by emergency physicians between 2010 and 2018 were extracted, measures carried out were evaluated and categorized into three groups: specific emergency interventions (category I), general medical interventions (category II) and no medical activity (category III). The frequency of occurrence of these categories was compared and incidences of individual measures per 100,000 inhabitants were calculated. RESULTS A total of 15,409 primary responses and 322 secondary transports were extracted and analyzed. The annual rate of system activation rose almost continuously from 1442 calls in 2010 to 2301 calls in 2018. The 3687 (23.4%) cancellations resulted in 12,044 patient contacts. Of these, 2842 (18%) calls were coded as category I, 7372 (47%) as category II and 5518 (35%) as category III. The frequency of specific emergency measures and general medical interventions was estimated at 157/100,000 and 409/100,000 inhabitants, respectively. CONCLUSIONS No specific emergency physician interventions were required in the majority of call-outs. The current model of preclinical care does not appear to be patient-oriented and efficient. Furthermore, the low proportion of critically ill and injured patients already leads to a reduction in attractiveness for emergency physicians and may introduce the threat of quality issues due to insufficient routine experience and lack of training.
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Affiliation(s)
- G Prause
- Klinische Abteilung für Allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich.
| | - S Orlob
- Klinische Abteilung für Allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - D Auinger
- Klinische Abteilung für Allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - M Eichinger
- Klinische Abteilung für Allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - P Zoidl
- Klinische Abteilung für Allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - M Rief
- Klinische Abteilung für Allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
| | - P Zajic
- Klinische Abteilung für Allgemeine Anästhesiologie, Notfall- und Intensivmedizin, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich
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Chotalia M, Pirrone C, Mangham T, Torlinska B, Mullhi R, England K, Torlinski T. The Predictive Applicability of Liberal vs Restrictive Intubation Criteria in Adult Patients With Suspected Inhalation Injury-A Retrospective Cohort Study. J Burn Care Res 2020; 41:1290-1296. [PMID: 32504540 DOI: 10.1093/jbcr/iraa092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study compares the ability of liberal vs restrictive intubation criteria to detect prolonged intubation and inhalation injury in burn patients with suspected inhalation injury. Emerging evidence suggests that using liberal criteria may lead to unnecessary intubation in some patients. A single-center retrospective cohort study was conducted in adult patients with suspected inhalation injury admitted to intensive care at Queen Elizabeth Hospital, Birmingham between April 2016 and July 2019. Liberal intubation criteria, as reflected in local guidelines, were compared to restrictive intubation criteria, as outlined in the American Burn Association guidelines. The number of patients displaying positive characteristics from either guideline was compared to the number of patients who had prolonged intubation (more than 48 hours) and inhalation injury. In detecting a need for prolonged intubation (n = 85), the liberal criteria had greater sensitivity (liberal = 0.98 [0.94-1.00] vs restrictive = 0.84 [0.75-0.93]; P = .013). However, the restrictive criteria had greater specificity (restrictive = 0.96 [0.89-1.00] vs liberal = 0.48 [0.29-0.67]; P < .001). In detecting inhalation injury (n = 72), the restrictive criteria were equally sensitive (restrictive = 0.94 [0.87-1.00] vs liberal = 0.98 [0.84-1.00]; P = .48) and had greater specificity (restrictive = 0.86 [0.72-1.00] vs liberal = 0.04 [0.00-0.13]; P < .001). In patients who met liberal but not restrictive criteria, 65% were extubated within 48 hours and 90% did not have inhalation injury. Liberal intubation criteria were more sensitive at detecting a need for prolonged intubation, while restrictive criteria were more specific. Most patients intubated based on liberal criteria alone were extubated within 48 hours. Restrictive criteria were highly sensitive and specific at detecting inhalation injury.
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Affiliation(s)
- Minesh Chotalia
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Christine Pirrone
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Australia
| | - Thomas Mangham
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Barbara Torlinska
- Centre for Patient Reported Outcome Research, Institute of Applied Health Research, University of Birmingham,, UK
| | - Randeep Mullhi
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Kaye England
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Tomasz Torlinski
- Department of Anaesthetics and Critical Care, West Midlands Burns Centre, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, UK
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Hatchimonji JS, Dumas RP, Kaufman EJ, Scantling D, Stoecker JB, Holena DN. Questioning dogma: does a GCS of 8 require intubation? Eur J Trauma Emerg Surg 2020; 47:2073-2079. [PMID: 32382780 PMCID: PMC7223660 DOI: 10.1007/s00068-020-01383-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/24/2020] [Indexed: 11/26/2022]
Abstract
Background There is no evidence supporting intubation for a Glasgow Coma Scale (GCS) of 8. We investigated the effect of intubation in trauma patients with a GCS 6–8, with the hypothesis that intubation would increase mortality and length of stay. Methods We studied adult patients with GCS 6–8 from the 2016 National Trauma Data Bank. Intubated and non-intubated patients were compared using inverse probability weighted regression adjustment (IPWRA) to control for injury severity and patient characteristics. Outcomes were mortality, intensive care unit length of stay (ICU LOS), and total LOS. Stratified analysis was performed to investigate the effect in patients with and without head injuries. Results Among 6676 patients with a GCS between 6 and 84,078 were intubated within 1 h of arrival to the emergency department. The overall mortality rate was 15.1%. IPWRA revealed an increase in mortality associated with intubation (OR 1.05, 95% CI 1.03, 1.06). The results were similar in patients with head injuries (OR 1.04, 95% CI 1.02, 1.06) and without (OR 1.06, 95% CI 1.03, 1.10). Among the 5,742 patients admitted to the ICU, intubation was associated with a 14% increase in ICU LOS (95% CI 8–20%; 5.5 vs. 4.8 days; p < 0.001). The overall length of stay was 27% longer (95% CI 19.8–34.3%) among intubated patients (mean 7.7 vs 6.0 days; p < 0.001). Conclusion Among patients with GCS of 6 to 8, intubation on arrival was associated with an increase in mortality and with longer ICU and overall length of stay. The use of a strict threshold GCS to mandate intubation should be revisited.
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Affiliation(s)
- Justin S. Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA USA
| | - Ryan P. Dumas
- Division of General and Acute Care Surgery, Department of Surgery, University of Texas Southwestern Medical
Center at Dallas, Dallas, TX USA
| | - Elinore J. Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Dane Scantling
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
| | - Jordan B. Stoecker
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, 4 Maloney, Philadelphia, PA USA
| | - Daniel N. Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA USA
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Intubation of emergency traumatic head injury patient outside the operation theatre: Cross-sectional study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Stahl JL, Miller AC. What's New in Critical Illness and Injury Science? A Look into Trauma Airway Management. Int J Crit Illn Inj Sci 2020; 10:1-3. [PMID: 32322546 PMCID: PMC7170347 DOI: 10.4103/ijciis.ijciis_14_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 01/10/2020] [Accepted: 02/25/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jennifer L. Stahl
- Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, North Carolina, USA
- Department of Critical Care Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, North Carolina, USA
| | - Andrew C. Miller
- Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, North Carolina, USA
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Elmer J, Brown F, Martin-Gill C, Guyette FX. Prevalence and Predictors of Post-Intubation Hypotension in Prehospital Trauma Care. PREHOSP EMERG CARE 2019; 24:461-469. [PMID: 31566990 DOI: 10.1080/10903127.2019.1670300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Prehospital care of severe trauma patients often involves endotracheal intubation (ETI), which has complications. The frequency and predictors of post-ETI hypotension and cardiac arrest are not well defined in this population. We sought to derive and validate a scoring system that predicts post-ETI hypotension in prehospital patients and to describe the impact of hypotension on outcome. We performed an observational cohort study including normotensive adult trauma patients requiring ETI, treated from 2001 to 2018 by critical care transport providers in a regional air medical transport system. We divided eligible patients into a derivation cohort (2001-2010) and validation cohort (2011-2018) for analysis. We identified predictors of new systolic hypotension (<90 mmHg) or cardiac arrest within 15 minutes of ETI then developed and validated a scoring system that stratified patients into low, moderate and high risk. We included 4,866 subjects, 3,127 in the derivation and 1,739 in the validation cohort. Post-ETI hypotension occurred in 11% and 21%, respectively; 5% of each cohort experienced post-ETI cardiac arrest. Major independent predictors of post-ETI hypotension were age, pre-ETI systolic blood pressure and pre-ETI oxygen saturation. We developed a well-calibrated scoring system based on these major and several minor risk factors. Applying our system, 890 (33%) derivation patients and 550 (37%) validation patients were higher risk for post-ETI adverse outcomes. Of these, 21% and 33% respectively experienced post-ETI hypotension and 6% and 4%, respectively suffered post-ETI cardiac arrest. Patients at high risk for post-ETI hypotension or arrest are common and identifiable in prehospital trauma care.
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Prehospital airway procedures performed in trauma patients by ground forces in Afghanistan. J Trauma Acute Care Surg 2019. [PMID: 29521802 DOI: 10.1097/ta.0000000000001866] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Airway management is of critical importance in combat trauma patients. Airway compromise is the second leading cause of potentially survivable death on the battlefield and accounts for approximately 1 in 10 preventable deaths. Reports from the Iraq and Afghanistan wars indicate 4% to 7% incidence of airway interventions on casualties transported to combat hospitals. The goal of this study was to describe airway management in the prehospital combat setting and document airway devices used on the battlefield. METHODS This study is a retrospective review of casualties that required a prehospital lifesaving airway intervention during combat operations in Afghanistan. We obtained data from the Prehospital Trauma Registry that was linked to the Department of Defense Trauma Registry for outcome data for the time period between January 2013 and September 2014. RESULTS Seven hundred five total trauma patients were included, 16.9% required a prehospital airway management procedure. There were 132 total airway procedures performed, including 83 (63.4%) endotracheal intubations and 26 (19.8%) nasopharyngeal airway placements. Combat medics were involved in 48 (36.4%) of airway cases and medical officers in 73 (55.3%). Most (94.2%) patients underwent airway procedures due to battle injuries caused by explosion or gunshot wounds. Casualties requiring airway management were more severely injured and less likely to survive as indicated by Injury Severity Score, responsiveness level, Glascow Coma Scale, and outcome. CONCLUSION Percentages of airway interventions more than tripled from previous reports from the wars in Afghanistan and Iraq. These changes are significant, and further study is needed to determine the causes. Casualties requiring airway interventions sustained more severe injuries and experienced lower survival than patients who did not undergo an airway procedure, findings suggested in previous reports. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.
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Kuza CM, Vavilala MS, Speck RM, Dutton RP, McCunn M. Use of Survey and Delphi Process to Understand Trauma Anesthesia Care Practices. Anesth Analg 2019. [PMID: 29533256 DOI: 10.1213/ane.0000000000002863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Few trauma guidelines evaluate and recommend anesthesiology practices and there are no trauma anesthesia-specific guidelines. There is no information on how anesthesiologists perceive clinical practice patterns. Our objective was to understand the perceptions of anesthesiologists regarding trauma anesthesia practices. METHODS A survey assessing anesthesia management of trauma patients was distributed to 21,491 anesthesiologists. A subset of 10 of these questions was subsequently reviewed by a trauma anesthesiology focus group through a 3-round web-based Delphi process. A question was deemed to have respondent consensus if the response with the highest percentage of agreement was unchanged between rounds 1 and 2. RESULTS A total of 2360 anesthesiologists (11% response rate) responded to the survey. Results demonstrated that the practitioners' answers conflicted with existing surgical trauma society recommendations (ie, when to transfuse component therapy), and several areas that lacked any guidelines, resulted in response variability among anesthesiologists where not 1 answer achieved >75% agreement (ie, intubation technique of choice for patients with uncleared cervical spine). Thirteen trauma anesthesiologists participated in round 1 (response rate 100%), and 12 responded in rounds 2 and 3 (response rate 92%) of the Delphi process. None of the questions received 100% agreement. Consensus was achieved on 9 of 10 statements pertaining to trauma anesthesia care. Consensus was not reached on the intubating technique in a hemodynamically unstable patient with an uncleared cervical spine with deficits. Delphi participant opinion conflicted with existing guidelines on 2 statements: the use of cricoid pressure, and when to begin blood component therapy. CONCLUSIONS There are several important areas of trauma anesthesia practice where guidelines do not exist and several where existing guidelines are not endorsed by the majority of practitioners who completed our survey. The lack of consensus on trauma anesthesia management and the variation in survey responses demonstrate a need to develop evidence-based trauma anesthesia guidelines.
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Affiliation(s)
- Catherine M Kuza
- From the Department of Anesthesiology and Critical Care, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Monica S Vavilala
- Department of Anesthesiology, Pain Medicine and Pediatrics, University of Washington, Seattle, Washington
| | - Rebecca M Speck
- Biostatistics and Epidemiology and.,Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Maureen McCunn
- Department of Anesthesiology, University of Maryland, Division of Trauma Anesthesiology, Baltimore, Maryland
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Pap R, van Loggerenberg C. A comparison of airway management devices in simulated entrapment-trauma: a prospective manikin study. Int J Emerg Med 2019; 12:15. [PMID: 31286862 PMCID: PMC6615147 DOI: 10.1186/s12245-019-0233-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 06/25/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION In the patient entrapped after a motor vehicle collision (MVC), advanced airway management may need to be performed before extrication. The aim of this study was to compare four airway management devices utilized by paramedics in a simulated entrapped patient. METHODS Twenty-six paramedics performed advanced airway management on a manikin seated in the driver's seat (right side) of a car. Access was through the opened door only. The airway devices were the Macintosh laryngoscope and the Airtraq optical laryngoscope to facilitate the endotracheal intubation (ETI), the laryngeal mask airway (LMA) Supreme and the laryngeal tube (LT). Time to first successful ventilation and number of attempts required for successful placement were measured. Following each placement, participants rated the degree of difficulty. For ETI, participants ranked the achieved glottic view using Cormack-Lehane grades (CLG). Finally, participants were asked which airway management device they preferred. RESULTS The LMA Supreme had the shortest mean time to first successful ventilation (16.7 s, CI [0.95] 14.9-18.6). Insertion of the LMA Supreme and ETI with the Macintosh laryngoscope had 100% first-attempt success. The LMA Supreme was rated least difficult to insert (mean score 1.7/10 (CI [0.95] 1.2-2.1)). Compared to the Macintosh, the Airtraq laryngoscope facilitated superior laryngoscopy (CLG I view 46.2% and 80.8%, respectively). Most participants (10/26; 38%) chose the Macintosh laryngoscope as their preferred technique, followed closely by the LMA Supreme (9/26; 35%). CONCLUSION The LMA Supreme took the least amount of time and was the easiest to be inserted. Extraglottic airway devices may be beneficial alternative airway management devices to be considered by paramedics in the entrapped patient. Endotracheal intubation using the Macintosh laryngoscope was performed competently by participating paramedics. The Airtraq enabled superior laryngoscopy but resulted in poorer first-pass success rate.
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Affiliation(s)
- Robin Pap
- School of Science and Health, Western Sydney University, Locked Bag 1797, Penrith, Sydney, NSW, 2751, Australia.
| | - Charl van Loggerenberg
- ER Consulting Inc., Johannesburg, South Africa.,School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Wahba S, Tammam T, Saeed A. Comparative study of awake endotracheal intubation with Glidescope video laryngoscope versus flexible fiber optic bronchoscope in patients with traumatic cervical spine injury. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2012.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- S.S. Wahba
- Department of Anesthesia and Intensive Care, Faculty of Medicine , Ain-Shams Universities , Egypt
| | - T.F. Tammam
- Department of Anesthesia and Intensive Care, Faculty of Medicine , Suez-Canal Universities , Egypt
| | - A.M. Saeed
- Department of Anesthesia and Intensive Care, Faculty of Medicine , Ain-Shams Universities , Egypt
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Abstract
PURPOSE OF REVIEW To review the current use of continuous lateral rotational therapy (CLRT) in patients with thoracic injuries and its impact on clinical course, complications and outcome. RECENT FINDINGS Patient positioning is a key factor in the treatment of severe thoracic injuries and CLRT, and intermittent supine and prone position are basic options. There is a lack of randomized controlled studies for trauma patients with chest injury undergoing kinetic therapy as standard of care. A positive effect of kinetic therapy for prevention of secondary respiratory complications has been reported; nevertheless, no positive effect on mortality or length of hospital stay could be affirmed so far. In general, standardized therapeutic regimes for treatment of chest trauma have been implemented, including ventilator settings and positioning therapy. However, the available data do not allow a clear recommendation for rotational/kinetic therapy or prone positioning as superior or inferior. SUMMARY The benefit of changing the patients' position for secret mobilization and recruitment of atelectasis after chest trauma and therefore preventing secondary complications seems to be self-evident. Since only few studies report about the utility of CLRT in critically ill chest trauma patients, randomized controlled multicenter trials are necessary to analyze the overall benefit of such means.
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„Rapid sequence induction and intubation“ beim aspirationsgefährdeten Patienten. Anaesthesist 2018; 67:568-583. [DOI: 10.1007/s00101-018-0460-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/23/2018] [Accepted: 05/03/2018] [Indexed: 12/19/2022]
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Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients: Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department. Emerg Med Int 2018; 2018:5649476. [PMID: 29984001 PMCID: PMC6015695 DOI: 10.1155/2018/5649476] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 05/16/2018] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to determine complication rates and possible risk factors of expert-performed endotracheal intubation (ETI) in patients with trauma, in both the prehospital setting and the emergency department. We also investigated how the occurrence of ETI-related complications affected the survival of trauma patients. This single-center retrospective observational study included all injured patients who underwent anesthesiologist-performed ETI from 2007 to 2017. ETI-related complications were defined as hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, dental trauma, cuff leak, and mainstem bronchus intubation. Of the 537 patients included, 23.5% experienced at least one complication. Multivariable logistic regression analysis revealed that low Glasgow Coma Scale Score (adjusted odds ratio [AOR], 0.93; 95% confidence interval [CI], 0.88-0.98), elevated heart rate (AOR, 1.01; 95% CI, 1.00-1.02), and three or more ETI attempts (AOR, 15.71; 95% CI, 3.37-73.2) were independent predictors of ETI-related complications. We also found that ETI-related complications decreased the likelihood of survival of trauma patients (AOR, 0.60; 95% CI, 0.38-0.95), independently of age, male sex, Injury Severity Score, Glasgow Coma Scale Score, and off-hours presentation. Our results suggest that airway management in trauma patients carries a very high risk; this finding has implications for the practice of airway management in injured patients.
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Amagasa S, Tsuji S, Matsui H, Uematsu S, Moriya T, Kinoshita K. Prognostic factors of acute neurological outcomes in infants with traumatic brain injury. Childs Nerv Syst 2018; 34:673-680. [PMID: 29249074 DOI: 10.1007/s00381-017-3695-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study is to clarify risk factors for poor neurological outcomes and distinctive characteristics in infants with traumatic brain injury. METHODS The study retrospectively reviewed data of 166 infants with traumatic intracranial hemorrhage from three tertiary institutions in Japan between 2002 and 2013. Univariate and multivariate analyses were used to identify clinical symptoms, vital signs, physical findings, and computed tomography findings associated with poor neurological outcomes at discharge from the intensive care unit. RESULTS In univariate analysis, bradypnea, tachycardia, hypotension, dyscoria, retinal hemorrhage, subdural hematoma, cerebral edema, and a Glasgow Coma Scale (GCS) score of ≤ 12 were significantly associated with poor neurological outcomes (P < 0.05). In multivariate analysis, a GCS score of ≤ 12 (OR = 130.7; 95% CI, 7.3-2323.2; P < 0.001), cerebral edema (OR = 109.1; 95% CI, 7.2-1664.1; P < 0.001), retinal hemorrhage (OR = 7.2; 95% CI, 1.2-42.1; P = 0.027), and Pediatric Index of Mortality 2 score (OR = 1.6; 95% CI, 1.1-2.3; P = 0.018) were independently associated with poor neurological outcomes. Incidence of bradypnea in infants with a GCS score of ≤ 12 (25/42) was significantly higher than that in infants with GCS score of > 12 (27/90) (P = 0.001). CONCLUSIONS Infants with a GCS score of ≤ 12 are likely to have respiratory disorders associated with traumatic brain injury. Physiological disorders may easily lead to secondary brain injury, resulting in poor neurological outcomes. Secondary brain injury should be prevented through early interventions based on vital signs and the GCS score.
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Affiliation(s)
- Shunsuke Amagasa
- Department of Pediatric Intensive Care, Nagano Children's Hospital, 3100, Toyoshina, Azumino City, Nagano, 399-8288, Japan. .,Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan.
| | - Satoshi Tsuji
- Department of Emergency Medicine and Transport Service, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Hikoro Matsui
- Department of Pediatric Intensive Care, Nagano Children's Hospital, 3100, Toyoshina, Azumino City, Nagano, 399-8288, Japan
| | - Satoko Uematsu
- Department of Emergency Medicine and Transport Service, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847, Amanuma-cho, Omiya-ku, Saitama City, Saitama, 330-8503, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchikamichou, Itabashi-ku, Tokyo, 173-8610, Japan
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Treille J, Bessereau J, Douplat M, Treille JM, Michelet P, de La Coussaye JE, Claret PG. Physiopathologie et prise en charge de l’hypotension post-intubation en séquence rapide. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0756-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Noveanu J, Amsler F, Ummenhofer W, von Wyl T, Zuercher M. Assessment of Simulated Emergency Scenarios: Are Trained Observers Necessary? PREHOSP EMERG CARE 2017; 21:511-524. [DOI: 10.1080/10903127.2017.1302528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Neurologic complications in critically ill pregnant patients. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190440 DOI: 10.1016/b978-0-444-63599-0.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.
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Almahmoud K, Teuben M, Andruszkow H, Horst K, Lefering R, Hildebrand F, Pape HC, Pfeifer R. Trends in intubation rates and durations in ventilated severely injured trauma patients: an analysis from the TraumaRegister DGU®. Patient Saf Surg 2016; 10:24. [PMID: 27822309 PMCID: PMC5094000 DOI: 10.1186/s13037-016-0109-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 10/13/2016] [Indexed: 01/15/2023] Open
Abstract
Background Endotracheal intubation in severely injured patients is known to be a risk factor for systemic complications. We aimed to examine the changes in intubation rates and durations in severely injured trauma patients, and rates of the systemic complications associated with ventilation changes by using a large trauma registry over the period of 13 years. Methods Patient demographics, Injury Severity Score (ISS), ventilation days, ventilation free days (VFD), and prevalence of systemic complications (sepsis and multiple organ failure (MOF)) were obtained from the TraumaRegister DGU® and were compared over the study period. Results During the study period (2002 – 2014), 35,232 patients were recorded in TraumaRegister DGU®. 72.7 % of patients (n = 25,629) were intubated, and 27.3 % (n = 9603) of patients did not require mechanical ventilation throughout their hospital stay. The mean age was 48 ± 21 years, mean ISS was 27.9 ± 11.5, mean length of ICU stay was 11.7 ± 13.8 days, mean time on mechanical ventilator was 7.1 ± 11.3 days, and mean ventilation free days (spontaneous respiration) was 19.5 ± 11.9 days. We observed a reduction in the intubation rates (87.5 % in 2002 versus 63.6 % in 2014), and early extubation (10 ventilation days in 2002, and 5.9 days in 2014) over time. Conclusion Our study reveals a reduction in intubation rates and ventilation duration during the observation period. Moreover, we were able to observe decreased incidence of systemic complications such as sepsis over the 13 year study period, while no changes in incidence of MOF were registered. The exact relationship can not be proven in our study. This needs to be addressed in further analysis.
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Affiliation(s)
- Khalid Almahmoud
- Department of Orthopedics Trauma Surgery, University of Aachen Medical Center, 52074 Aachen, Germany ; Harald Tscherne Laboratory, RWTH Aachen University, 52074 Aachen, Germany
| | - Michel Teuben
- Department of Orthopedics Trauma Surgery, University of Aachen Medical Center, 52074 Aachen, Germany ; Harald Tscherne Laboratory, RWTH Aachen University, 52074 Aachen, Germany
| | - Hagen Andruszkow
- Department of Orthopedics Trauma Surgery, University of Aachen Medical Center, 52074 Aachen, Germany ; Harald Tscherne Laboratory, RWTH Aachen University, 52074 Aachen, Germany
| | - Klemens Horst
- Department of Orthopedics Trauma Surgery, University of Aachen Medical Center, 52074 Aachen, Germany ; Harald Tscherne Laboratory, RWTH Aachen University, 52074 Aachen, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, 51109 Cologne, Germany
| | - Frank Hildebrand
- Department of Orthopedics Trauma Surgery, University of Aachen Medical Center, 52074 Aachen, Germany ; Harald Tscherne Laboratory, RWTH Aachen University, 52074 Aachen, Germany
| | - Hans Christoph Pape
- Department of Orthopedics Trauma Surgery, University of Aachen Medical Center, 52074 Aachen, Germany ; Harald Tscherne Laboratory, RWTH Aachen University, 52074 Aachen, Germany
| | - Roman Pfeifer
- Department of Orthopedics Trauma Surgery, University of Aachen Medical Center, 52074 Aachen, Germany ; Harald Tscherne Laboratory, RWTH Aachen University, 52074 Aachen, Germany
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Easby J, Dodds C. Emergency induction of anaesthesia in the prehospital setting: a review of the anaesthetic induction agents. TRAUMA-ENGLAND 2016. [DOI: 10.1191/1460408604ta317oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The standard of prehospital care is improving in many trauma systems around the world. For patients surviving the primary injury, the optimal prehospital interven tions remain debatable. Current evidence suggests that patients with severe head injury may benefit from advanced airway management, most commonly per formed by rapid sequence induction of anaesthesia and orotracheal intubation. The ‘best choice’ induction agent remains unclear, and choice seems to depend on local preferences and the skill mix of the prehospital care team. In this review we look at the recent evidence for selected hypnotic agents.
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Affiliation(s)
- J Easby
- James Cook University Hospital, Cleveland, UK,
| | - C Dodds
- James Cook University Hospital, Cleveland, UK
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Sanguanwit P, Trainarongsakul T, Kaewsawang N, Sawanyawisuth K, Sitthichanbuncha Y. Is retrograde intubation more successful than direct laryngoscopic technique in difficult endotracheal intubation? Am J Emerg Med 2016; 34:2384-2387. [PMID: 27629490 DOI: 10.1016/j.ajem.2016.08.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/28/2016] [Accepted: 08/28/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Difficult airway intubation is an emergency condition both at the emergency department (ED) and in out-of-hospital situations. Retrograde intubation (RI) is another option for difficult airway management. There are limited data regarding the successful rate of RI compared with direct laryngoscopy (DL) intubation, the commonly used method in the ED. METHODS This study was a randomized, controlled trial. Participants were randomly assigned to either the RI or the DL technique to attempt intubation on a difficult airway mannequin (Cormack and Lehane grades 3-4). First, all participants received the training on the RI or DL, and then attempted intubation. After the training, the participants had 2 chances to intubate. The outcomes of this study included numbers of participants who successfully intubated and times of successful intubation. RESULTS There were 100 participants in this study, with 50 participants in each group (RI and DL). There was no significant difference between the groups in terms of experience at the ED or DL. The successful rate of intubation was significantly higher in the RI group than in the DL group (74% vs 12%; P = .001), as was the rate of successful intubation on the first attempt (34% vs 8%; P = .026). There were no statistical differences between physicians and medical students in any of the 3 outcomes in either the DL or RI group. CONCLUSIONS The RI technique had a higher success rate in difficult airway intubation than the DL technique, regardless of experience.
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Affiliation(s)
- Pitsucha Sanguanwit
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital Mahidol University, Bangkok, Thailand
| | - Thavinee Trainarongsakul
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital Mahidol University, Bangkok, Thailand
| | - Noppanan Kaewsawang
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital Mahidol University, Bangkok, Thailand
| | - Kittisak Sawanyawisuth
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Research Center in Back, Neck Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University, Khon Kaen, Thailand; Internal Medicine Research Group, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Yuwares Sitthichanbuncha
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital Mahidol University, Bangkok, Thailand.
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Yumul R, Elvir-Lazo OL, White PF, Durra O, Ternian A, Tamman R, Naruse R, Ebba H, Yusufali T, Wong R, Hernandez Conte A, Farnad S, Pham C, Wender RH. Comparison of the C-MAC video laryngoscope to a flexible fiberoptic scope for intubation with cervical spine immobilization. J Clin Anesth 2016; 31:46-52. [DOI: 10.1016/j.jclinane.2015.12.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 12/16/2015] [Accepted: 12/28/2015] [Indexed: 01/31/2023]
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Böhmer AB, Poels M, Kleinbrahm K, Lefering R, Paffrath T, Bouillon B, Defosse JM, Gerbershagen MU, Wappler F, Joppich R. Change of initial and ICU treatment over time in trauma patients. An analysis from the TraumaRegister DGU®. Langenbecks Arch Surg 2016; 401:531-40. [PMID: 27114102 DOI: 10.1007/s00423-016-1428-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/05/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Clinical guidelines have been standardized for pre- and in-hospital trauma management in the last decades. Therefore, it is known that prehospital management has changed significantly. Furthermore, in-hospital course may be altered to reduce complications and length of stay (LOS). However, the development of trauma patient in-hospital management as well as LOS in the intensive care unit (ICU) has not been investigated systematically over a long-term period in Germany. Aim of our study is to examine the changes in in-hospital management and LOS in the ICU in moderately and severely injured patients. METHODS Patients documented in the TraumaRegister DGU® (TR-DGU) of the German Trauma Society from 2000 to 2011 and admitted to ICU were included in this study. Demographic data, the pattern of injury, injury severity, duration of mechanical ventilation, LOS in the ICU, hospital LOS, and discharge destination were evaluated. The mean values and the standard deviations are shown. The constant variables were calculated with changes over time analyzed by linear regression analysis, and categorical variables were calculated with the chi-square test. RESULTS A total of 18,048 patients were analyzed. The rate of patients being intubated at the time of ICU admission decreased from 86.8 % in 2000 to 60.0 % in 2011 (p < 0.001). The time of mechanical ventilation decreased from 7.5 ± 10.5 to 4.7 ± 8.7 days. The intensive care unit LOS was reduced from 11.7 ± 12.8 to 9.0 ± 11.3 days and the length of hospital stay from 27.9 ± 28.7 to 21.1 ± 20.4 days (both p < 0.01). The ICU LOS remained stable in the subgroup of mechanically ventilated patients (12.7 ± 13.2 day in 2000, 12,6 ± 12.9 in 2011, p = 0.6), whereas it was reduced in non-mechanically ventilated patients (5.5 ± 6.8 days in 2000, 3.6 ± 4.5 days in 2011; p < 0.001). CONCLUSIONS The reduction LOS in the analyzed dataset is mainly explained by the relevantly reduced rate of patients being intubated at the time of ICU admission. Our data demonstrate that trauma patients' in-hospital course is influenced by reduced intubation rate at the time of ICU admission.
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Affiliation(s)
- Andreas B Böhmer
- Department of Anesthesiology, Hospital Cologne-Merheim, Cologne Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany.
| | - Marcel Poels
- Department of Anesthesiology, Hospital Cologne-Merheim, Cologne Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Kathrin Kleinbrahm
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne, Germany
| | - Thomas Paffrath
- Department of Traumatology and Orthopedic Surgery, Hospital Cologne-Merheim, Cologne Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Bertil Bouillon
- Department of Traumatology and Orthopedic Surgery, Hospital Cologne-Merheim, Cologne Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Jerome Michel Defosse
- Department of Anesthesiology, Hospital Cologne-Merheim, Cologne Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Mark U Gerbershagen
- Department of Anesthesiology, Hospital Cologne-Merheim, Cologne Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Frank Wappler
- Department of Anesthesiology, Hospital Cologne-Merheim, Cologne Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Robin Joppich
- Department of Anesthesiology, Hospital Cologne-Merheim, Cologne Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
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Ko JI, Ha SO, Koo MS, Kwon M, Kim J, Jeon J, Park SH, Shim S, Chang Y, Park T. Comparison of intubation times using a manikin with an immobilized cervical spine: Macintosh laryngoscope vs. GlideScope vs. fiberoptic bronchoscope. Clin Exp Emerg Med 2015; 2:244-249. [PMID: 27752604 PMCID: PMC5052909 DOI: 10.15441/ceem.15.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/09/2015] [Accepted: 09/16/2015] [Indexed: 11/23/2022] Open
Abstract
Objective Airway management in patients with suspected cervical spine injury is classified as a “difficult airway.” The best device for managing difficult airways is not known. Therefore, we conducted an intubation study simulating patients with cervical spine injury using three devices: a conventional Macintosh laryngoscope, a video laryngoscope (GlideScope), and a fiberoptic bronchoscope (MAF-TM). Success rates, intubation time, and complication rates were compared. Methods Nine physician experts in airway management participated in this study. Cervical immobilization was used to simulate a difficult airway. Each participant performed intubation using airway devices in a randomly chosen order. We measured the time to vocal cord visualization, time to endotracheal tube insertion, and total tracheal intubation time. Success rates and dental injury rates were compared between devices. Results Total tracheal intubation time using the Macintosh laryngoscope, GlideScope, and fiberoptic bronchoscope was 13.3 (range, 11.1 to 20.1), 14.9 (range, 12.7 to 22.3), and 19.4 seconds (range, 14.1 to 32.5), respectively. Total tracheal intubation time differed significantly among the devices (P=0.009). Success rates for the Macintosh laryngoscope, GlideScope, and fiberoptic bronchoscope were 98%, 96%, and 100%, respectively, and dental injury rates were 5%, 19%, and 0%, respectively. Conclusion The fiberoptic bronchoscope required longer intubation times than the other devices. However, this device had the best success rate with the least incidence of dental injury.
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Affiliation(s)
- Jung-In Ko
- Department of Emergency Medicine, National Medical Center, Seoul, Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Min Seok Koo
- Department of Anesthesia, National Medical Center, Seoul, Korea
| | - Miyoung Kwon
- Department of Anesthesia, National Medical Center, Seoul, Korea
| | - Jieun Kim
- Department of Anesthesia, National Medical Center, Seoul, Korea
| | - Jin Jeon
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So Hee Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sangwoo Shim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungbuk National University, Cheongju, Korea
| | - Taejin Park
- Department of Emergency Medicine, National Medical Center, Seoul, Korea
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[Interdisciplinary management of trauma patients : Update 3 years after implementation of the S3 guidelines on treatment of patients with severe and multiple injuries]. Anaesthesist 2015; 63:852-64. [PMID: 25227879 DOI: 10.1007/s00101-014-2375-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries. AIM This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies. MATERIAL AND METHODS In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations. RESULTS The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients. CONCLUSION The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.
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Abstract
PURPOSE OF REVIEW Securing the airway to provide sufficient oxygenation and ventilation is of paramount importance in the management of all types of emergency patients. Particularly in severely injured patients, strategies should be adapted according to useful recent literature findings. RECENT FINDINGS The role of out-of-hospital endotracheal intubation in patients with severe traumatic brain injury as prevention of hypoxia still persists, and the ideal neuromuscular blocking agent will be a target of research. Standardized monitoring, including capnography and the use of standardized medication protocols without etomidate, can reduce further complications. Prophylactic noninvasive ventilation may be useful for patients with blunt chest trauma without respiratory insufficiency. SUMMARY An algorithm-based approach to airway management can prevent complications due to inadequate oxygenation or procedural difficulties in trauma patients; therefore, advanced equipment for handling a difficult airway is needed. After securing the airway, ventilation must be monitored by capnography, and normoventilation involving the early use of protective ventilation with low-tidal volume and moderate positive end-expiratory pressure must be the target. After early identification of patients with blunt chest trauma at risk for respiratory failure, noninvasive ventilation might be a treatment strategy, which should be evaluated in future research.
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Comparison of tracheal intubation and alternative airway techniques performed in the prehospital setting by paramedics: a systematic review. CAN J EMERG MED 2015; 12:135-40. [DOI: 10.1017/s1481803500012161] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT
This systematic review included controlled clinical trials comparing tracheal intubation (TI) with alternative airway techniques (AAT) (bag-mask ventilation and use of extraglottic devices) performed by paramedics in the prehospital setting. A priori outcomes to be assessed were survival, neurologic outcome, airway management success rates and complications. We identified trials using EMBASE, MEDLINE, CINAHL, The Cochrane Library, Web of Science, author contacts and hand searching. We included 5 trials enrolling a total of 1559 patients. No individual study showed any statistical difference in outcomes between the TI and AAT groups. Because of study heterogeneity, we did not pool the data. This is the most comprehensive review to date on paramedic trials. Owing to the heterogeneity of prehospital systems, administrators of each system must individually consider their airway management protocols.
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Abstract
AbstractThe majority of maxillofacial gunshot wounds are caused by suicide attempts. Young men are affected most often. When the lower one-third of the face is involved, airway patency (1.6% of the cases) and hemorrhage control (1.9% of the cases) are the two most urgent complications to monitor and prevent. Spinal fractures are observed with 10% of maxillary injuries and in 20% of orbital injuries. Actions to treat the facial gunshot victim need to be performed, keeping in mind spine immobilization until radiographic imaging is complete and any required spinal stabilization accomplished. Patients should be transported to a trauma center equipped to deal with maxillofacial and neurosurgery because 40% require emergency surgery. The mortality rate of maxillofacial injuries shortly after arrival at a hospital varies from 2.8% to 11.0%. Complications such as hemiparesis or cranial nerve paralysis occur in 20% of survivors. This case has been reported on a victim of four gunshot injuries. One of the gunshots was to the left mandibular ramus and became lodged in the C4 vertebral bone.MaurinO, de RégloixS, DubourdieuS, LefortH, BoizatS, HouzeB, CulomaJ, BurlatonG, TourtierJP. Maxillofacial gunshot wounds. Prehosp Disaster Med. 2015;30(3):14.
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Nakao S, Kimura A, Hagiwara Y, Hasegawa K. Trauma airway management in emergency departments: a multicentre, prospective, observational study in Japan. BMJ Open 2015; 5:e006623. [PMID: 25652800 PMCID: PMC4322207 DOI: 10.1136/bmjopen-2014-006623] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Although successful airway management is essential for emergency trauma care, comprehensive studies are limited. We sought to characterise current trauma care practice of airway management in the emergency departments (EDs) in Japan. DESIGN Analysis of data from a prospective, observational, multicentre registry-the Japanese Emergency Airway Network (JEAN) registry. SETTING 13 academic and community EDs from different geographic regions across Japan. PARTICIPANTS 723 trauma patients who underwent emergency intubation from March 2010 through August 2012. OUTCOME MEASURES ED characteristics, patient and operator demographics, methods of airway management, intubation success or failure at each attempt and adverse events. RESULTS A total of 723 trauma patients who underwent emergency intubation were eligible for the analysis. Traumatic cardiac arrest comprised 32.6% (95% CI 29.3% to 36.1%) of patients. Rapid sequence intubation (RSI) was the initial method chosen in 23.9% (95% CI 21.0% to 27.2%) of all trauma patients and in 35.5% (95% CI 31.4% to 39.9%) of patients without cardiac arrest. Overall, intubation was successful in ≤3 attempts in 96% of patients (95% CI 94.3% to 97.2%). There was a wide variation in the initial methods of intubation; RSI as the initial method was performed in 0-50.9% of all trauma patients among 12 EDs. Similarly, there was a wide variation in success rates and adverse event rates across the EDs. Success rates varied between 35.5% and 90.5% at the first attempt, and 85.1% and 100% within three attempts across the 12 EDs. CONCLUSIONS In this multicentre prospective study in Japan, we observed a high overall success rate in airway management during trauma care. However, the methods of intubation and success rates were highly variable among hospitals.
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Affiliation(s)
- Shunichiro Nakao
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Yusuke Hagiwara
- Department of Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Beleña JM, Gasco C, Polo CE, Vidal A, Núñez M, Lopez-Timoneda F. Laryngeal mask, laryngeal tube, and Frova introducer in simulated difficult airway. J Emerg Med 2014; 48:254-9. [PMID: 25453860 DOI: 10.1016/j.jemermed.2014.09.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 07/01/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of supraglottic devices is rising in the prehospital management of difficult airway; moreover, we think that patients with multiple trauma or cervical instability can take advantage of these devices without opening or retiring the cervical collar. OBJECTIVE To compare speed and ease of use between Laryngeal Tube S (LTS) and the Ambu AuraOnce laryngeal mask (LMA).Our second objective was to evaluate changing these devices to an endotracheal tube (ETT) using a Frova introducer. METHODS We studied the use of LTS and LMA in an experimental model, represented by a manikin with a rigid cervical collar and a limited mouth opening. This study was carried out in Complutense University of Madrid with 145 2(nd)-year students for the degree in Dentistry who have knowledge of the airway but lack experience in intubation. Number of attempts and time for the device's insertion were measured, as well as time for the exchange maneuver using the Frova introducer. RESULTS Insertion of all devices was possible on the first attempt; time for insertion was LTS 12.2 ± 1.28 s and LMA 6.87 ± 0.97 s. Once these devices were inserted, a Frova introducer is used to perform an exchange by an endotracheal tube; all devices could be exchanged on the first attempt, and exchange time was LTS 26.9 ± 1.2 s and LMA 16.79 ± 1.32 s. Results for both time for insertion and exchange of the LMA were significantly lower than those for the LTS (p < 0.001). CONCLUSION The method used can be considered quick and easy, even for personnel inexperienced in intubation. This exchange maneuver has not been described previously, so we can consider it as a new application of the Frova introducer.
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Affiliation(s)
- José M Beleña
- Department of Anaesthesiology and Critical Care, Sureste University Hospital, Arganda del Rey, Madrid, Spain; Department of Anaesthesiology, Faculty of Medicine/Odontology, Complutense University of Madrid, Madrid, Spain
| | - Carmen Gasco
- Department of Anaesthesiology, Faculty of Medicine/Odontology, Complutense University of Madrid, Madrid, Spain
| | - Carlos E Polo
- Community of Madrid Emergency Services (SUMMA 112), Madrid, Spain
| | - Alfonso Vidal
- Department of Anaesthesiology, Faculty of Medicine/Odontology, Complutense University of Madrid, Madrid, Spain
| | - Mónica Núñez
- Department of Anaesthesiology and Critical Care, Ramón y Cajal University Hospital, Madrid, Spain
| | - Francisco Lopez-Timoneda
- Department of Anaesthesiology, Faculty of Medicine/Odontology, Complutense University of Madrid, Madrid, Spain
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Comparison of the Macintosh, McCoy, Airtraq laryngoscopes and the intubating laryngeal mask airway in a difficult airway with manual in-line stabilisation: a cross-over simulation-based study. Eur J Anaesthesiol 2014; 30:544-9. [PMID: 23685784 DOI: 10.1097/eja.0b013e3283615b80] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Patients with multisystem trauma undergoing intubation with manual in-line stabilisation (MILS) have a higher incidence of difficult or failed intubations. OBJECTIVE To compare the effectiveness of the Macintosh laryngoscope with three other intubating devices in a high fidelity simulation model. DESIGN Cross-over, simulation-based study. SETTING Tertiary referral and level 1 trauma centre between June and November 2011. PARTICIPANTS Thirty-five experienced airway physicians. INTERVENTION Each participant performed tracheal intubations on a Laerdal SimMan manikin in both a normal airway and a difficult airway scenario with MILS. The devices utilised in a randomised order were the Macintosh, McCoy, Airtraq laryngoscopes and the intubating laryngeal mask airway (iLMA). MAIN OUTCOME MEASURES The primary outcome was time to intubation. Success rates, grade of laryngoscopy and force of intubation were also measured. RESULTS One hundred and forty intubations were attempted by 35 participants in both the normal and MILS scenarios. In the normal airway, there was no difference in success rates and time to intubation. In the difficult airway with MILS, there was no difference in success rates. However, the Airtraq was associated with a longer time to intubation than the Macintosh, McCoy and iLMA, 39.3, 26.7, 23.3, 39.3, 22.8 s, respectively (P < 0.0001). The Airtraq delivered the best glottic view and lowest force of intubation in both scenarios (P < 0.0001), but was associated with the only failed intubation in the study. The McCoy was associated with a significant improvement in the glottic visualisation (P < 0.05) and reduction in the force of intubation (P <0.0001) compared with the Macintosh. CONCLUSION In this manikin study, the McCoy demonstrated multiple advantages over the Macintosh. The iLMA was associated with the fastest time to intubation and minimum force of insertion.
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Lockey DJ, Crewdson K, Lossius HM. Pre-hospital anaesthesia: the same but different. Br J Anaesth 2014; 113:211-9. [PMID: 25038153 DOI: 10.1093/bja/aeu205] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Advanced airway management is one of the most controversial areas of pre-hospital trauma care and is carried out by different providers using different techniques in different Emergency Medical Services systems. Pre-hospital anaesthesia is the standard of care for trauma patients arriving in the emergency department with airway compromise. A small proportion of severely injured patients who cannot be managed with basic airway management require pre-hospital anaesthesia to avoid death or hypoxic brain injury. The evidence base for advanced airway management is inconsistent, contradictory and rarely reports all key data. There is evidence that poorly performed advanced airway management is harmful and that less-experienced providers have higher intubation failure rates and complication rates. International guidelines carry many common messages about the system requirements for the practice of advanced airway management. Pre-hospital rapid sequence induction (RSI) should be practiced to the same standard as emergency department RSI. Many in-hospital standards such as monitoring, equipment, and provider competence can be achieved. Pre-hospital and emergency in-hospital RSI has been modified from standard RSI techniques to improve patient safety, physiological disturbance, and practicality. Examples include the use of opioids and long-acting neuromuscular blocking agents, ventilation before intubation, and the early release of cricoid pressure to improve laryngoscopic view. Pre-hospital RSI is indicated in a small proportion of trauma patients. Where pre-hospital anaesthesia cannot be carried out to a high standard by competent providers, excellent quality basic airway management should be the mainstay of management.
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Affiliation(s)
- D J Lockey
- North Bristol NHS Trust, Bristol BS16 1LE, UK London's Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK
| | - K Crewdson
- London's Air Ambulance, Barts Health NHS Trust, London E1 1BB, UK
| | - H M Lossius
- Department of Research and Development, The Norwegian Air Ambulance Foundation, Holterveien 24, PO Box 94, N-1441 Drøbak, Norway Field of Pre-hospital Critical Care, Network for Medical Sciences, University of Stavanger, Kjell Arholmsgate 41, Stavanger 4036, Norway
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Reisner A, Chen X, Kumar K, Reifman J. Prehospital Heart Rate and Blood Pressure Increase the Positive Predictive Value of the Glasgow Coma Scale for High-Mortality Traumatic Brain Injury. J Neurotrauma 2014; 31:906-13. [DOI: 10.1089/neu.2013.3128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrew Reisner
- Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaoxiao Chen
- Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland
| | - Kamal Kumar
- Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland
| | - Jaques Reifman
- Biotechnology High Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, Ft. Detrick, Maryland
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Cheng W, Ran Z, Wei L, La-na D, Xiao-zhuo Z, Yan-hua R, Fang-gang N, Guo-an Z. Pathological changes of the three clinical types of laryngeal burns based on a canine model. Burns 2014; 40:257-67. [DOI: 10.1016/j.burns.2013.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 03/24/2013] [Accepted: 06/03/2013] [Indexed: 11/17/2022]
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Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. J Trauma Acute Care Surg 2013; 75:212-9. [PMID: 23823612 DOI: 10.1097/ta.0b013e318293103d] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Many resuscitation scenarios include the use of emergency intubation to support injured patients. New video-guided airway management technology is available, which may minimize the risk to patients from this procedure. METHODS This was a controlled clinical trial conducted in the trauma receiving unit in a university-affiliated urban hospital in which 623 consecutive adult patients requiring emergency airway management were prospectively randomized to intubation with either the direct laryngoscope (DL) or the GlideScope video laryngoscope (GVL) device. RESULTS The primary outcome was survival to hospital discharge. There was no significant difference in mortality between the GVL group (28 [9%] of 303) and the DL group (24 [8%] of 320) (p = 0.43) for all patients. Within a smaller cohort identified retrospectively, there was a higher mortality rate seen in the subgroup of patients with severe head injuries (head Abbreviated Injury Scale [AIS] score > 3) who were randomized to intubation with GVL (22 [30%] of 73) versus DL (16 [14%] of 112) (p = 0.047). Among all patients, median intubation duration in seconds was significantly higher for the GVL group (median, 56; interquartile range, 40-81) than for the DL group (median, 40; interquartile range, 24-68) (p < 0.001). Among those with severe head injuries, median intubation duration in seconds was also significantly higher for the GVL group (median, 74) than for the DL group (median, 65) (p < 0.003). Correspondingly, this group also experienced a greater incidence of low oxygen saturations of 80% or less (27 [50%] of 54 for the GVL group and 15 [24%] of 63 for the DL group; p = 0.004). There were no significant differences between the two groups in first-pass success (80% for GVL and 81% for DL, p = 0.46). CONCLUSION Use of the GlideScope did not influence survival to hospital discharge among all patients and was associated with longer intubation times than direct laryngoscopy. Among the video laryngoscope cohort, a smaller subgroup of severe head injury trauma patients identified retrospectively seemed to be associated with a greater incidence of hypoxia of 80% or less and mortality.
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Lossius HM, Krüger AJ, Ringdal KG, Sollid SJM, Lockey DJ. Developing templates for uniform data documentation and reporting in critical care using a modified nominal group technique. Scand J Trauma Resusc Emerg Med 2013; 21:80. [PMID: 24279612 PMCID: PMC4222125 DOI: 10.1186/1757-7241-21-80] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 11/18/2013] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Clinical practice in trauma and critical care is predominantly derived from quantitative observational cohort studies based on data retrospectively collected from medical records. Such data create uncontrolled bias and influence external and internal validity, thereby hindering systematic reviews. Templates or standards for uniform documenting and scientific reporting may result in high quality and internationally standardised data being collected on a regular basis, enhance large international multi-centre studies, and increase the quality of evidence. Templates or standards may be developed using multidisciplinary expert panel consensus methods.We present three consensus processes aimed at developing templates for documenting and scientific reporting. We discuss the advantages, limitations, and possible future improvements of our method. METHODS The template preparation was based on expert panel consensus derived through a modified nominal group technique (NGT) method that combined the traditional Delphi method with the traditional NGT method in a four-step process. RESULTS Standard templates for documenting and scientific reporting were developed for major trauma, pre-hospital advanced airway handling, and physician-staffed pre-hospital EMS. All templates were published in scientific journals. CONCLUSION Our modified NGT consensus method can successfully be used to establish templates for reporting trauma and critical care data. When used in a structured manner, the method uses recognised experts to achieve consensus, but based on our experiences, we recommend the consensus process to be followed by feasibility, reliability, and validity testing.
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Affiliation(s)
- Hans Morten Lossius
- Department of Research and Development, Norwegian Air Ambulance Foundation, Holterveien 24, Drøbak 1441, Norway.
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Goldberg SA, Leatham A, Pepe PE. Year in review 2012: Critical Care--Out-of-hospital cardiac arrest and trauma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:248. [PMID: 24267483 PMCID: PMC4059384 DOI: 10.1186/cc13128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
In 2012 Critical Care published many articles pertaining to the resuscitation of out-of-hospital cardiac arrest and trauma. In this review, we summarize several of these articles, including those regarding advances in resuscitation techniques and methods. We examine articles pertaining to prehospital endotracheal intubation, the use of specialized devices for cardiopulmonary resuscitation and policies regarding transport destinations for both cardiac arrest and trauma patients. Articles on the predictors of outcome in both pediatric and adult populations are evaluated, including articles on the effects of obesity on survival from hemorrhage and pediatric outcomes from traumatic cardiac arrest. The effects of the type and volume of resuscitation fluids for both adult and pediatric patients are discussed, as are the factors contributing to hypothermia in trauma patients.
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Lockey DJ, Avery P, Harris T, Davies GE, Lossius HM. A prospective study of physician pre-hospital anaesthesia in trauma patients: oesophageal intubation, gross airway contamination and the 'quick look' airway assessment. BMC Anesthesiol 2013; 13:21. [PMID: 24024531 PMCID: PMC3848683 DOI: 10.1186/1471-2253-13-21] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 09/03/2013] [Indexed: 11/24/2022] Open
Abstract
Background In trauma patients intubated in a physician-led pre-hospital trauma service we prospectively examined the rate of misplaced tracheal tubes, the presence and nature of gross airway contamination, and the value of ‘quick look’ airway assessment to identify patients with subsequent difficult laryngoscopy. Methods Patients requiring pre-hospital intubation in a 16 month period were included. Intubation success rate, misplaced tracheal tube rate, Cormack and Lehane grade, and the presence and nature of gross airway contamination were recorded at laryngoscopy. Tube placement was verified with carbon dioxide detection and chest x-ray. After visual assessment physicians stated whether laryngoscopy was expected to be a straightforward or ‘difficult’. The assessment was compared to subsequent laryngoscopy grade. Results 400 patients had attempted intubation and 399 were successfully intubated. 42 were in cardiac arrest and intubated without drugs. There were no oesophageal or misplaced tracheal tubes. Gross airway contamination was reported in 177 of 400 patients (44%), of which ¾ was from the upper airway. Unconscious patients had higher contamination rates (57%) than conscious patients (34%) (p ≤ 0.0001). As a test of difficult intubation, the ‘quick look’ generated sensitivity 0.597 and specificity 0.763 (PPV and NPV were 0.336 and 0.904 respectively). Conclusion This study suggests that when physicians perform pre-hospital anaesthesia they have high intubation success rates and the use of ETCO2 monitoring reduces or eliminates undetected misplaced tracheal tubes. We found high rates of airway contamination; mostly blood from the upper airway. The ‘quick look’ airway assessment had some utility but is unreliable in isolation.
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Affiliation(s)
- David J Lockey
- London's Air Ambulance, Department of Pre-hospital Care, Royal London Hospital, London E1 1BB, UK.
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Does the use of a bougie reduce the force of laryngoscopy in a difficult airway with manual in-line stabilisation? Eur J Anaesthesiol 2013; 30:563-6. [DOI: 10.1097/eja.0b013e3283631609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Parker Flex-It intubation stylet versus a 90-degree curved stylet during intubation with the McGrath videolaryngoscope performed by novices: a manikin study with 5 airway scenarios. J Clin Anesth 2013; 25:624-8. [PMID: 23988799 DOI: 10.1016/j.jclinane.2013.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 07/02/2013] [Accepted: 07/06/2013] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To compare the Parker Flex-It intubation stylet with a 90-degree curved stylet using the McGrath videolaryngoscope in 5 airway scenarios (from easy to difficult) in a manikin. DESIGN Prospective, randomized study. SETTING Academic hospital. SUBJECTS 20 staff anesthesiologists with no previous experience in videolaryngoscopy. MEASUREMENTS Subjects performed a total of 200 intubations with the McGrath Series 5 videolaryngoscope and completed a questionnaire afterwards. RESULTS Overall success rate was significantly higher with the Parker Flex-It intubation stylet (96 successful intubations with the Parker Flex-It vs 79 intubations in the 90° curved stylet group; P < 0.05). Intubation time was not significantly different. Subjects rated the Parker Flex-It intubation stylet as the better device for intubation with the McGrath videolaryngoscope in routine or emergency situations. CONCLUSION Intubation of the manikin with the McGrath videolaryngoscope had more success with the Parker Flex-It intubation stylet than a 90° curved stylet.
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A standardized rapid sequence intubation protocol facilitates airway management in critically injured patients. J Trauma Acute Care Surg 2013. [PMID: 23188232 DOI: 10.1097/ta.0b013e318270dcf5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the emergency department (ED) of a teaching hospital, rapid sequence intubation (RSI) is performed by physicians with a wide range of experience. A variety of medications have been used for RSI, with potential for inadequate or excessive dosing as well as complications including hypotension and the need for redosing. We hypothesized that the use of a standardized RSI medication protocol has facilitated endotracheal intubation requiring less medication redosing and less medication-related hypotension. METHODS An RSI medication protocol (ketamine 2 mg/kg intravenously administered and rocuronium 1 mg/kg intravenously administered, or succinylcholine 1.5 mg/kg intravenously administered) was implemented for all trauma patients undergoing ED intubation at a Level I trauma center. We retrospectively reviewed patients for the 1-year period before (PRE) and after (KET) the protocol was instituted. Data collected included age, sex, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) score of the head/face, AIS score of the chest, RSI drugs, need for redosing, time to intubation, indication for RSI, and number of RSI attempts. RESULTS During the study period, 439 patients met inclusion criteria; 266 without protocol (PRE) and 173 with protocol (KET). Patients were severely injured with a mean ISS of 24 and median AIS score of the head/face of 3. Dosing in the KET group was appropriate with a mean dose of 1.9-mg/kg ketamine administered. Compliance after KET introduction approached 90%. Fifteen patients in the PRE group required redosing of medication versus three in the KET group (p < 0.05, χ). For patients younger than 14 years, (26 in PRE and 10 in KET), 2 patients in the PRE group required redosing and none in the KET group (not significant). In all patients, mean time from drug administration to intubation decreased from 4 minutes to 3 minutes. CONCLUSION A standardized medication protocol simplifies RSI and allows efficient airway management of critically injured trauma patients in the ED of a teaching hospital. Incorporation of ketamine avoids potential complications of other commonly used RSI medications. LEVEL OF EVIDENCE Therapeutic study, level IV.
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